February 20, 2010

Health experts: Most repeat C-sections unnecessary

Michelle Williams is three months' pregnant and determined to experience childbirth the way nature intended. But because her previous baby was delivered through an incision in her abdomen and uterus — a cesarean section — she has to travel more than an hour from her home in Channahon to find an obstetrician willing to let her try for a vaginal birth.

One out of every three pregnant women now has a C-section, the most common surgical procedure in the U.S. The skyrocketing C-section rate has been hotly debated in birthing and medical communities, yet little attention has been paid to one of the consequences: Once a woman has a C-section, she often has to fight to deliver subsequent babies the old-fashioned way, if a hospital or obstetrician allows her to try it at all.

Repeat C-sections have become so routine that 90 percent of pregnant women who have the surgery give birth that way again. That is a concern to health experts, who say vaginal births after a cesarean, or VBACs, should be far more common.

Successful VBACs result in better health outcomes for the mother and the baby and cost several thousand dollars less than cesarean deliveries, according to the American Congress of Obstetricians and Gynecologists, or ACOG. The organization recommends that VBACs be offered in low-risk cases.

Experts point out that although the attempt carries a risk of uterine rupture, the chance it will happen is relatively low: 0.5 percent. Meanwhile, C-sections carry all the risks of a major surgery. Compared with having a vaginal birth, a woman delivering by C-section experiences more physical problems, longer recovery and more emotional issues on average, studies show. Research also has found babies born by cesarean are less likely to be breastfed and more likely to experience breathing problems at birth and asthma as they get older.

Yet the VBAC rate, 9.2 percent, is a far cry from the objective set by the Centers for Disease Control and Prevention: 37 percent. In Illinois, the rate was 11 percent in 2008, down from 38.6 percent a decade earlier.

In the rural parts of the state, the dictum "once a cesarean, always a cesarean" rings particularly true: In northwest Illinois, the VBAC rate is as low as 3.9 percent, according to the Illinois Department of Public Health. Twenty-two percent of Illinois hospitals don't offer the procedure, according to a survey by the International Cesarean Awareness Network, a grass-roots group that works to lower the rate of unnecessary cesarean sections.

From the early 1980s until 1996, the VBAC rate crept up as doctors — and insurance companies — encouraged C-section veterans to try one. But "Physicians were pressured into offering VBAC to unsuitable candidates," according to ACOG. As more VBACs occurred, the number of highly publicized uterine ruptures rose.

Safety fears, however, were just one factor. Legal pressures, professional guidelines, and patient and physician preferences also created a VBAC backlash. In March, the National Institutes of Health will hold its first-ever VBAC conference to explore why the rate continues to fall, even though 73 percent of the women who try VBACs are successful.

"The liability issue is huge," said Dr. Joseph Pavese, chairman of the obstetrics department at Advocate Christ Medical Center in Oak Lawn, where 97 percent of pregnant women with a previous C-section have another one. "Parents expect good outcomes, and physicians are reluctant to try difficult deliveries. If the baby is not perfect, there is possible litigation."

Once a woman undergoes a C-section, the resulting scar tissue is weaker than the uterine muscle. If the scar opens during labor, it would require an emergency C-section. Certain factors — induction of labor, or a vertical (rather than horizontal) incision — can increase the risk of rupture.

In 99.5 percent of the cases, nothing goes awry. But if the scar gives way, results can be catastrophic; the baby has a 10 percent chance of dying or suffering brain damage.

Over the years, "The risk of uterine rupture has not changed," said Dr. Howard Strassner, director of maternal and fetal medicine at Rush University Medical Center. "What has changed is individual tolerance for risk. It reached the point where no one wants to be associated with an adverse outcome."

In the 1990s, research that suggested VBACs were dangerous — and a pro-cesarean editorial — published in the New England Journal of Medicine immediately affected practice, said Gene Declercq, a professor of community sciences at the Boston University School of Public Health. But more recent and balanced research showing VBACs are as safe — if not safer — than repeat C-sections hasn't had the same effect, said DeClercq, who researches maternity care practice and policy in the U.S. and abroad.

What crippled the idea of a VBAC, however, was a simple word change. In 1998, ACOG advised that physicians should be "readily available" to provide emergency care because of the dangers of a uterine rupture. Eight months later, the American Congress of Obstetricians and Gynecologists changed the wording to "immediately available," and many small hospitals in rural areas stopped doing VBACs.

Katherine Shaw Bethea Hospital in Dixon, which handles about 365 deliveries a year, was one of more than a dozen Illinois hospitals that subsequently dropped VBACs because an on-site anesthesiologist wasn't always immediately available.

VBACs are also banned at Blessing Hospital in Quincy, which touts itself as "the largest and most sophisticated medical center in a 100-mile radius." Hospital officials declined to explain why.

VBAC-tivists say women need true informed consent and a choice.

"It's illegal to enforce a ban on how our bodies are designed," said doula and childbirth educator Desiree Andrews, of Colorado Springs, president of the International Cesarean Awareness Network. "But evidence-based practice has been crowded out of the hospital setting in favor of defensive medicine. As a result, too many women are subject to coerced cesareans because hospitals have banned VBACs."

C-sections are considered medically necessary when there's a problem with the baby's heart rate, the umbilical cord exits the uterus before the baby does, the mother's pelvis is too small to deliver a large baby, or the baby is in the breech position.

Women also can request the surgery, which influences doctors, said Strassner. A women who had prolonged labor with her first child and ended up with a C-section anyway often does not want to endure another labor without a guarantee that things will be different.

"Why do in 30 hours what you can do in 30 minutes?" said Jean Dalrymple, of Kansas City, whose second child is due March 22. Dalrymple said she has "lobbied early and often for the repeat C-section" even though her doctor offered her a VBAC.

Terrified by the thought of labor, Dalrymple, 38, said she respects women who want to experience a vaginal birth, but is "positive that God created the C-section for chickens like me."

Other women who request C-sections may be afraid of uterine rupture and misinformed about how frequently they occur, said Dr. Sarah Kilpatrick, who heads the department of obstetrics and gynecology at the University of Illinois College of Medicine in Chicago.

"Or they want to plan their delivery or haven't thought about the complication of a repeat section," said Kilpatrick. "Women still think it's like a zipper — you pull the baby out and zip it back up. But surgery is harder the second time. There's an increased chance of injury to the bladder and bowel in the patient and other complications."

To get a VBAC, however, women often have to advocate for it. Some even feel they have to lie.

Chicago's Mariana Patzelt, 27, who had two previous C-sections, planned to drive from her home in Norwood Park to UIC to deliver her third baby. But after laboring too long at home in hopes of reducing her chances of a C-section, she ended up delivering in the emergency room of a nearby hospital.

When doctors there asked whether she had had any previous surgeries, she said no.

"The whole time I was hoping they didn't see the scar," she said. "I knew if I would have said yes, it would have blown my chances and I wouldn't be able to fight hard enough for everything I worked for.

"Hospitals treat birth as a medical condition, a disease they have to fix rather than something natural we've been doing since the beginning of time."

Channahon's Williams, 30, hopes to deliver her baby naturally in August. She plans to drive more than 40 miles to the University of Chicago Medical Center to try for a VBAC to avoid the trauma she experienced with her first child, Sadie.

Williams and Sadie had complications from the cesarean surgery. Sadie was rushed from Joliet's Silver Cross Hospital to Children's Memorial Hospital in Chicago, and Williams felt unable to bond with her baby. Two months later, an infection landed Williams back in the hospital.

But she is realistic about her chances of a VBAC and just wants a healthy baby.

"If the VBAC doesn't go as planned, my husband and I are working on a birth plan to make the next C-section as peaceful and as beautiful as possible," she said. "Little things — like asking the doctor to hold up the baby as soon as it's born so that I can see — can make difference between a traumatic birth and a relaxing one."

Comments

Ms. Patzelt is the reason there are bad outcomes...I am a doctor and if a patient lies about doing cocaine or having 2 previous csections because she believes what she reads...then that patient should solely be responsible for the bad outcome...keep teaching your readers and my future patients to lie to me

Beautifully written, brave, and long-overdue! Hopefully this information will put a spotlight on practices that, though they have become "standard," seriously need to be reexamined and changed to put women and babies FIRST. Bravo.

I have had 3 children in 3 different ways. Baby #1 C-section, baby #2 VBAC with a spinal, baby #3 a baby that couldn't wait to get here so in the hospital, bam on the table, no meds at all, here is baby. I guess that would still count as a VBAC minus meds. If the patient is honest and straightforward about ALL medical conditions, including drug use,prior C-sections, ect, VBAC is the way to go. Our bodies were made for this, doctor's know best depending on each individual patient, plus the recovery is so much more pleasant and you are able to enjoy and care for your newborn quickly.

The incidence of adverse events from VBACs may be small, but the magnitude of damage caused by these rare events is horrible. The perinatal death of a baby that has made it through a full, healthy gestation is devastating to all involved. And those babies who don't die, but incur anoxic brain injury, may be in a worse situation. The morbidity for these children can be tremendous, and arguably worse than death. From mild CP to G-tubes, tracheostomies to VP shunts, the lives of these children and their families are irreparably changed.

I don't think that C-sections should be mandatory, but I don't think that there should be VBAC zealots who decry those institutions and societies who are concerned about their ability to manage potentially horrible outcomes that can occur with a VBAC.

I don't thin k she is encouraging people to lie. She is showing women sometimes feel afraid that their dream of a naturaL delivery will be taken away by a dr that does not agree w/vbac. I say tell them the truth-no one can make you sign c-section consents and it is illegal to turn away a woman in labor.

Horrible article.
You have the two worst examples.
One who lies to her drs and puts her life and babies life in jeopardy.
Another who says she has to drive to Chicago for a VBAC because no DR will do it in Joliet. I highly doubt that. I live in Joliet, had a csection and would have been allowed a VBAC with my second child at the other hospital in Joliet. She either didn't find a good DR or her insurance plan limited her options for DR's. We also are missing information as to why her baby was sent to Childrens and what type of infection she had. To much information is missing.
Csections are not necessarily the devil of deliveries. When medically necessarily they are the best options for mother and baby.
I support any woman who wants to have a VBAC that does their education that is more than this misdirected article.

Point taken. But bear in mind some patients (shouldn't, but do) lie because they have had traunmatic experiences in hosptials, treated like cattle or idiots during life changing moments (like becoming a mother) or coerced into things they do not want and may not need. Like, too often, a c section. So patients, don't lie, and doctors and nurses, treat every patient the way you'd want to see a loved one treated. Respectfully.

Due to a breech birth, I had to have a C-section with my first children. No other choice -- we all would have died otherwise.

With my second pregnancy, here's what I learned and it summarizes the article:

In 99.5 percent of VBACs, everything is fine. Great.

But in .5 percent of VBACs, there is a problem. In half of those situations, the mother did not heal strong enough from the first C-section so the baby is brain damaged or dead following an unproductive delivery. In the other half of those situations, the mother ruptures and the mother, the baby or both die.

Here's the translation for real mothers and their babies:

In every 200 VBACs, there is one case where the best outcome is the baby is brain damaged and the worst outcome is both mother and baby die.

I respect any woman who decides to proceed with a VBAC. To me, the article's claim that the risk of 0.5 "is relatively low" is not valid. The risk of a horrible outcome as described above is not 1 in 10,000 or even 1 in 1,000. It's 1 out of 200.

Yes, I am risk averse. My second birth via C-section brought a tremendously healthy baby and a very quick recovery for me (just like the first one). Again, I respect mothers who made another decision. But 1 in 200 is too high a risk to ignore blithely.

Whoa---Julie get your facts straight. C-sections are NOT medically necessary in cases of breech positioning except for the RARE cases of footling breech and babies over or under a certain size. There are MANY studies to support this. Yet another example along with VBACs where doctors and hospitals (and insurers) are NOT practicing evidence-based medicine!!!

Julie responds:
Sorry, I should have clarified: ACOG says they're medicall necessary. They also say women with two C-sections should not try for a vbac, but recent evidence conflicts with that.

I am currently in the fight for my VBAC, and it is one of the hardest things I have had to do. Through my nursing education and years of research after the unnecessary c-section delivery of my son, I learned how much safer for my child and myself it is to have a VBAC rather than another cesarean. I suffered months of wound packing after my c-section due to a wound dehiscence, a common complication of abdominal surgery, and one that was not explained to me beforehand. I am a perfect candidate for a VBAC according to my OB-GYN and my new-found Midwife. Unfortunately, due to VBAC bans in my area, I am left with no option other than to birth at home. Although I wish I had chosen a home birth with my son, I am nervous of a Home Birth VBAC. But it is my only option due to VBAC bans. As long as the ACOG guidelines are interpreted in this way, many MANY moms will be birthing at home when they would normally birth in a hospital. These doctors and hospitals may be saving their own backsides from guilt and lawsuits, but they are only removing our safety nets and leaving us with less than ideal options.

VBAC's are very dangerous and I would NEVER allow anyone I loved to do it. As a NICU RN, I have seen many go bad, too many to count. I have seen 1 mom and baby die in one and more than one baby die.
Mrs. Patzelt could have lost her life and the life of her baby for purely selfish reasons. I could not agree more with the post from the doctor above, she is 100% correct in her assessment. This is a misleading article and shame on you for putting this in people's head who have no medical knowledge.

Docbears.
Did you inform your patients that the reason you perform more c sections is because it is quicker and you don't want to wait for a long natural delivery even though a c section is more dangerous.You get paid more for a c section and you would rather pump these babies out like an assembly line in a factory because it is more money in your pocket. God made babies to be born naturally .

With all due respect docbears, I am sure there are patients who can cause bad outcomes. But Ms. Patzelt had a successful VBAC and everything is fine. Why are we not celebrating the successful birth and diving in to learn more about it? Almost all doctors talk about are "risks" and potentially bad outcomes. Never will they talk about the potentially good outcomes. But what happens when a case like Ms. Patzelt's comes along and she had a SUCCESSFUL VBAC after 2 c-sections? Instead of saying, "Gee... perhaps it is NOT as risky as we thought. Maybe the human body is more complex than us doctor's can truly wrap our education around." Why not humbly say... "this may lead us to new understandings of the amazing power of the human body and child birth." My wife and I went to the doctor to talk about a VBAC. (We have one son, with another on the way). Our doctor talked at length about all the potential risks that could occur with a VBAC. But I threw a curveball question at her... "What about the risks of having ANOTHER C-section?" She was stammered and admitted that the risks based on medical STATISTICS, proved that a 2nd c-section was RISKIER than a VBAC. Need I say more?

Wow... I like how "docbears" says "if a patient lies about doing cocaine or having 2 previous csections because she believes what she reads..." Nice that you try to compare a hard drug user with the mother in the story. Chill out doctor. And I love your first comment... "Ms. Patzelt is the reason there are bad outcomes..." Ok... so all of a sudden, doctors are perfect and don't make mistakes? My uncle works for the second largest law firm in the world and by far, their biggest legal department is medical malpractice and wrongful death. Doctors, pharmaceutical drugs, hospital administrators and nurses ALL have caused and continue to cause accidents, injury and death to hundreds of thousands of people every year. That is what your own medical journals admit. Gimme a break.

What a great article, THANK YOU for exposing the harsh reality that women are being forced into unnecessary surgeries because of doctor's fears.

As for "docbears", when doctors stop punishing women for telling the truth, ie: coercing them into surgery merely because of a past surgery, then maybe we'll talk about being honest with them. Comparing a VBAmC mother with a cocaine user is ridiculous and is a good example of the type of attitude women are fleeing from in the medical profession.

Perhaps if doctors weren't so quick to cut in the first place, women would not feel they have to lie to get the birth they want.
While we are on the subject, how about the FACT that C-Sections are most commonly performed between the hours of 8am to 5pm Monday through Friday? Now I could accept this if all of them were elective, but what about those doctors who aren't willing to wait for a woman to birth her baby vaginally because the doc's vacation is the next day, or tee time is just coming up, or a myriad of other reasons why medically unnecessary cesareans are performed.
Maybe if women weren't forced under the knife because the doctor would not be inconvenienced, maybe if more doctors viewed attending birth as the privilege it is instead of just a job, maybe if doctors were less afraid of the insurance companies and concentrated more on being CARE Providers to their patients, we would have less women lying to protect themselves and their babies.

You really compared a VBA2C to using cocaine? Really? Only weeks after a recent study shows that VBA3C carries no more risk than a repeat cesarean? THAT'S why women lie. Sure there are risks involved in VBAC. There are risks involved in labor for first time mother's, there are risks involved in repeat c/s but the medical community blows these risks out of proportion. If you don't want patients to lie to you, don't lie to them.

I left Korea (which has an even higher c-section rate than the US) and went to stay with my parents so I could VBAC. My first c-section was for breech and my second baby was breech as well. After flying half-way around the world, I had to drive two hours to have the baby turned by ECV. Three weeks later, I went into labor in my own, was driven to the hospital 2 hours away and had a very easy birth 2.5 hours after arriving at the hospital. The birth was so easy and well-supported but it is a shame I had to go so far to get the kind of support I needed and every woman deserves.

As for lying to doctors, if there were real choice and support, women wouldn't feel the need to lie.

My two sons were delivered by C-section. The first was an emergency and the second was elected. I must say that I was more than happy with both experiences. Most, if not all of the credit, goes to the wonderful treatment I received at Northwestern Memorial Hospital. Although my babies didn't come into the world the "natural" way, the births were non-traumatic and both physically and emotionally fulfilling to me as a woman and mother. I and my sons are all happy, healthy and very "bonded".

Therefore, I can't get but a little bit irked when I only hear the negative press about C-sections. Every woman's birthing experience will be different, whether it's vaginally or by C-section. I have talked to several pregnant women about my C-section experiences, and they are grateful that I relieved much of the anxiety they were feeling about facing a possible C-section delivery.

So ladies, please don't believe everything you read! Make your own choices by listening to your heart and don't let others make you feel guilty about those choices! Now as far as the negative press regarding NOT breast feeding, that's a whole other story....................

The problem, Docbears, rests not in your patients lying to you, but in a system so dysfunctional that it drives your patients to do so. They are NOT the cause of bad outcomes, and a few minutes of research would inform you as much. Your dismissive and defensive posture indicates that your concern is for your legal safety only.

docbears, create a system where VBAC women aren't scared into having 93% of their babies cut from their body, and they won't have to lie to you.

There is NO escuse for the dangerously high c-section rate in our country (some states near 50%!!!), other than failure to wait on the part of doctors like you. The US birth system with it's unacceptably high c-section rate does not have better outcomes than many other western countries, as a matter of fact, we fall surprisingly low. Rather than blaming your patients for doing what they must to avoid unnecessary surgery, why don't you work on your side of the equation to help improve birth in America.

Once again, random percentages generated by governing bodies. Three kids, three c-sections. A narrow pelvis was the cause of my surgeries. After laboring for 48 hours with the first one and having him go into fetal distress prior to emergency c-section, I wasn't about to put my second child through that. The 10 pound second child was even a Bigger mismatch to my pelvis than the first one according to my Dr.

I almost feel like the c-section debate is taking on the holier than thou tone of the breast feeding vs formula debate that rages among otherwise lucid women. Yes, it is surgery and has inherant risks. So does vaginal delivery as many women can attest.

I have two (too many) friends with children with Cerebal Palsey caused by lack of oxygen in an extended effort to deliver vaginally by the medical staff to EVER question a woman's right to chose a c-section just because some medical center doesn't want to skew their numbers of c-secstions.

whatever doc... try respecting your patients wishes for a change. your whole industry is paternalistic, misogynistic and abusive. even the female obgyns are woman hating £$£"s. one of the women in my moms group had a c sect after an attempted vbac and when she 'failed to progress' and needed the sect her female doc said 'serves you right for trying to vbac.' so whatever doc.